What we can do to prevent errors and improve patient safety

Start out with the conviction that absolute truth is hard to reach in matters relating to our fellow creatures, healthy or diseased, that slips in observation are inevitable even with the best trained faculties, that errors in judgement must occur in the practice of an art which consists largely in balancing probabilities—start, I say, with this attitude of mind. ... You will draw from your errors the very lessons which may enable you to avoid their repetition.

I’ve never amputated the wrong leg, nor for that matter tied off a common bile duct. Of course, as a nonproceduralist, I’ve had few opportunities to do such things.

However, in the face of intense publicity about the safety of medical encounters, I’ve strived to become more cognizant of medical “errors” in my own practice over the past few months.

I’ve found some worrisome trends. When time constraints are most pressing, I make mistakes, such as failing to carefully verify an elderly patient’s adherence to drug therapy, only to subsequently discover that she had been taking an inadequate dose. More than once, I’ve failed to fully engage patients and sent them home less informed than they should be.

Of course, no wrong legs were amputated, and none of these mistakes resulted in any adverse consequence to my patients. But they could have.

My experiences, which may sound familiar to many of you, exemplify the special problem we internists have in responding to the national debate about how to improve patient safety and reduce medical errors. Our process of care revolves around decision-making and communication, often in a time-pressured ambulatory setting. Our decisions come about from an amalgam of experience, moral values, evidence-based principles and, yes, imperfection.

“Failed processes”

Medical errors have been defined as “failed processes that are clearly linked to adverse outcomes.” According to a systems-theory perspective, even seemingly trivial processes that fail can lead to major adverse outcomes.

For internists, the key issue is prioritizing our efforts to identify and improve “failed processes.” We also need to avoid getting bogged down pursuing trivial issues at the expense of more important problems. This is no easy task, especially in the ambulatory setting.

Clearly, we can not be indifferent to such concerns or try to discredit estimates of the magnitude of medical errors. The Institute of Medicine’s reports on safety issues have raised public awareness to an extraordinary level. As a profession, we have a very small window of opportunity to propose and implement our own remedies before a bureaucratic remedy is imposed on us.

Steps toward improving safety

I have some suggestions for how we might proceed. First, we must all become better informed.

An ideal place to start is the November/December 2000 issue of Effective Clinical Practice (www.acponline.org/journals/ecp/pastiss/nd00.htm). In one intellectually satisfying evening, you can become well-grounded in the basic assumptions and policy implications of the patient safety movement.

Over the next year, other College publications, including ACP–ASIM Observer and Annals of Internal Medicine, will publish articles on patient safety. These sources will show that most serious medical errors—those with a high probability of causing patients harm—are attributable to flaws in systems of care, rather than individual physicians.

Later in the year, the College will distribute teaching tool kits on patient safety at regional meetings. These kits will contain easy-to-read handouts and education cards you can give to your patients.

Most experts agree that to make any substantive improvements in patient safety, we must document and track not just those processes that result in grievous harm, but also the “near misses” and day-to-day occurrences that aren’t discovered by conventional quality improvement or chart review processes. The mistakes I make when I get too busy are a perfect example.

Incentives for change

Every industry that has attempted to understand the root causes of errors has concluded that a climate of fear only thwarts improvement efforts. We must give physicians an incentive to voluntarily report any potentially harmful episodes. Through careful analysis, we can help change systems of care, whether in hospitals or small offices.

The College is strongly pushing for these types of solutions in meetings with elected officials. In early May, more than 120 College members from more than 35 states attended the College’s annual Leadership Day in Washington.

Internists expressed the College’s support for bills like the Patient Safety Act, which would establish a national system of voluntary error reporting. All members can get involved by voicing their opinions to their elected representatives. (For more information, go to www.acponline.org/advocacy/.)

Progress on patient safety begins with every individual internist’s careful introspection. As Osler pointed out more than 100 years ago, each of us can “draw from [our] errors the very lessons which may enable [us] to avoid their repetition.”

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